Personal Information

If you are interested in making a medical presentation, please let us know your subject:

Badge name 🛈

Special Meal Requirements: *

2.

Title *

First *

Middle 🛈

Surname *

Date of Birth *+

Special Meal Required? *

Gender *

If you are interested in making a medical presentation, please let us know your subject:

Badge name 🛈

Special Meal Requirements: *

3.

Title *

First *

Middle 🛈

Surname *

Date of Birth *+

Special Meal Required? *

Gender *

If you are interested in making a medical presentation, please let us know your subject:

Badge name 🛈

Special Meal Requirements: *

Passport Information

* Note: A valid passport (expiring no earlier than 6 months after your scheduled departure from the region) is required for entry into the destination.

1.

Passport No. *

Date of Issue *+

Date of Expiry *+

Place of Issue *

Nationality *

Profession *

2.

Passport No. *

Date of Issue *+

Date of Expiry *+

Place of Issue *

Nationality *

Profession *

3.

Passport No. *

Date of Issue *+

Date of Expiry *+

Place of Issue *

Nationality *

Profession *

Contact Information

Street Address *

Address Line 2

City *

Province/State/Region *

Zip/Postal Code *

Country *

Phone # (home/cell) *

Phone # (business)

Phone # (fax)

Email Address *

Email Address (secondary)

Tour Pricing

Please place a check in each applicable box (tour item) for each passenger.

All prices are per passengerand are quoted in CANADIAN $ (this is unlike many programs offered by other companies including a Galapagos cruise component which are quoted in US$ - and, with a premium of almost 40% when paying in US$, this makes a significant difference).

2. Business class upgrade costs above are an estimate and are subject to confirmation of both availability and rate at the actual time of booking.

3. Upgrades to business class must be paid in full at time of booking.

Travel Insurance

IMPORTANT - Mandatory Travel Health Insurance

Effective May 1, 2018, the Ecuadorian government requires all tourists to carry proof of health insurance that covers them during their stay in Ecuador.

Your present existing medical insurance coverage from your home country may cover you when overseas (you would need to check this with your health insurance provider and ensure that they can provide you with a letter, or copy of your policy, stating that you have medical coverage overseas). If your existing medical insurance coverage does not provide for coverage overseas, it will be necessary for you to purchase our Manulife All Inclusive Insurance coverage (see page 27)which includes unlimited health coverage while in the destination.

Proof of medical insurance while in Ecuador will need to be presented at Ecuadorian Immigration upon your arrival into Quito and failure to do so will result in you being denied entry into the country.

Through Manulife Insurance, we offer two insurance coverage options:

Non-Medical Inclusive

There are significant inherent cancellation penalties associated with your booking as detailed in our booking terms and conditions and this insurance package provides coverage for all monies paid for your trip if you should have to cancel due to medical, or other listed, reasons either relating to yourself or a member of your immediate family. It also covers you for trip interruption costs short notice return flight home etc) for medical reasons again, either relating to yourself or an immediate family member as well as flight and travel accident and baggage insurance.

All-Inclusive Plan

Provides coverage for all the components in the non-medical package, plus unlimited health coverage while in the destination.

"Cancel for any reason (CFAR)" coverage - NEW and at no additional cost !!So long as you purchase either of the two insurance policies above at the same time as your tour booking, you are automatically entitled to this added benefit of CFAR coverage whereby, if you need to cancel your tour booking up to 14 days or more before departure for any reason, your policy will refund you up to a maximum of 50% of the cancellation penalties incurred. This is excellent peace of mind coverage to protect you against (50% of the) cancellation penalties incurred in a situation where the reason for cancellation is not one of the regular covered risks in your policy (ie it is essentially "change of mind" insurance).

A detailed overview of coverage benefits and limitations of each insurance policy that we offer through Manulife may be found at the link below. Please ensure that you review this document, including the specific non-eligibility provisions at the top of page 2:

Unfortunately, from a regulatory perspective, we are unable to offer travel insurance to non-Canadian residents. We recommend that you therefore organize your travel insurance (ideally medical, cancellation and trip interruption coverage) with a local provider. Please select "no insurance" below.

Choice of travel insurance: *

Non-Medical Inclusive

All-Inclusive Plan

No insurance

Each individual passenger's insurance premium is based upon their total insurable costs (total for all passengers is shown above using the "Calculate" button) and their age at the date of booking. Using this information, you may find amount of the premium using the table shown below. The insurance premium is due at the time of booking with the tour deposit. More payment information can be found in the next section.

Note: Total Insurable Costs relate to the total cost of your booking (including all taxes fees and miscellaneous other amounts) on a per person basis (as seen using the individual total calculations in the Tour Pricing section).

** Due to provincial travel insurance regulations, we are unable to directly sell Manulife Travel Insurance directly to clients that do not reside in Ontario. Instead, travel insurance must be taken out by clicking the Manulife Insurance link below:

This link can also be reached by clicking on the Manulife Insurance button under the "Useful Links and Files" section of our Upcoming Program webpage for this tour (www.doctorsontour.ca).

Choice of travel insurance: *

Non-Medical Inclusive (via Manulife web-link)

All-Inclusive Plan (via Manulife web-link)

No insurance

We cannot stress strongly enough the need for adequate insurance coverage regarding out of country medical, trip cancellation and trip interruption. If you believe that you already have adequate insurance, we would urge you to check the level of coverage particularly regarding trip cancellation and trip interruption as, for example, if the insurance is as a result of booking on your credit card, the coverage limits for trip cancellation and trip interruption can often be quite limited as to trip duration or insured $ amount in the event of a claim (for example, it is not uncommon for trip cancellation coverage to be limited to approximately $2,500 (and sometimes lower..) per booking (rather than per person) and for trip interruption to be limited to $1,000 per person – you would need to check with your credit card company for actual coverage levels).

If it is still your intention to decline our insurance, please place a checkmark in the box below. Otherwise, please select a travel insurance package from the selection above.

Insurance declined waiver *

I hereby decline the travel insurance offerings above on behalf of all passengers listed on this registration form

I hereby state that all passengers listed on this registration form have existing medical coverage which is valid in Ecuador for the duration of the tour and that proof of such medical coverage will be provided to the Ecuadorian Immigration authorities upon arrival into Ecuador. All passengers realize that if such proof of medical coverage is not provided, they will be denied entry into Ecuador.

Payment

- If Business class upgrades are purchased, the full upgrade cost is also due at time of booking

- Payable by credit card only with registration, non-refundable

BALANCE

- Final balance amount will be indicated on our invoice confirmation which will be provided to you following our receipt of this online registration form

- Due by no later than June 29, 2018 (For registrations received on or after this date, payment is required in full at the time of booking)

- Payable by credit card or cheque

PAYMENT METHOD

We accept payment by either cheque or credit card (Visa and Mastercard only; American Express not accepted)

PAYMENT BY CHEQUE

Upon receipt of our invoice confirmation, please send a cheque for your balance post-dated to June 29, 2018, payable to Doctors-on-Tour.

Balance payments must be made by cheque if you are taking advantage of our Repeat Customer Discount.

Doctors-on-Tour

20 Princeton Road

Toronto, On.

Canada

M8X 2E2

PAYMENT BY CREDIT CARD

Please complete the credit card information below. Even if you are paying the balance by cheque, deposits must be paid via credit card.

* All credit card data entered on our form is protected by SSL encryption and hosted on our secure server.

See the https:// secure website verification in the page URL (address).

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CCV (3-digit # on back of card) *

Is your credit card billing address the same as your mailing address provided in the "Contact Information" section? *

CREDIT CARD BILLING ADDRESS

Street Address *

Address Line 2

City *

Province/State/Region *

Zip/Postal Code *

Country *

Please indicate the method of payment for your final balance. *

Cheque

Credit Card

Please indicate the method of payment for your final balance. *

Cheque

** Since you are taking advantage of our Repeat Customer Discount, balance payments must be made by cheque. If you wish to pay your final balance by credit card, you must remove the Repeat Customer Discounts in the Tour Pricing section, at which point the 'Credit card' option will be available for selection above.

Credit card authorization *

I authorize "on-tour.ca" to bill the credit card above for the deposit and applicable insurance premium, as well as to automatically charge the credit card with the final balance due on June 29, 2018 as well as any additional chargeable items approved by myself in writing (including by electronic mail)

Credit card authorization *

I authorize "on-tour.ca" to bill the credit card above for the deposit and applicable insurance premium, as well as any additional chargeable items approved by myself in writing (including by electronic mail)